Filling out a death certificate: A better way is needed

I’ve always had nagging doubts about filling out death certificates.

An excellent article in American Medical News explores the “inexactitude” of the custom.

Doctors are never taught how to fill out the documents. The article quotes Randy Hanzlick, MD, chief medical examiner for Fulton County, GA:

Training is a big problem. There are very few medical schools that teach it,” he said. “For many physicians, the first time they see it is when they are doing their internship or residency and one of their patients dies. The nurse hands them a death certificate and says, “Fill this out.”

That’s pretty much how it works. Though sometimes the person that comes calling with the death certificate is a hospital clerk. And she will make you fill out the form carefully, using only “allowable” causes of death.

Of course, everyone dies from the same thing: lack of oxygen to the brain. But you can’t list that. Nor can you list common “jargon-y” favorites like “cardiopulmonary arrest,” “respiratory failure,” “sepsis,” or “multi-system organ failure.” All of which are true, but too inexact to be useful.

It’s intimidating to be the one to “pronounce” someone dead, and be the final arbiter of the cause. Isn’t that why we have medical examiners/pathologists?

We don’t autopsy patients much anymore, a trend that concerns many in the industry but doesn’t seem likely to change. That leaves interns and residents (at teaching hospitals) and community docs (in the real world) in charge of filling out these important statistical and historic documents.

When you care for a patient that dies in the hospital, your guess as to the cause can be pretty close. But without allowing for processes and instead requiring specifics (“pneumonia” instead of “respiratory failure”) it’s no wonder that when I was a resident, it seemed as though every patient died of a heart attack (“myocardial infarction”). This was one of the “allowable” causes that seemed to apply whether it made the most sense or not.

If someone is really old and their body starts giving out, we can nearly always choose to say it’s because of their heart giving out. But what they most likely die from is “brain failure”–but there’s no category or term for that. The brain is the conductor of the body’s orchestra; but aside from “stroke” (“cerebrovascular accident or disease”) we usually don’t list the brain in any of the causes (though stroke itself is #3 after heart disease and cancer).

Imagine getting a call from the police that a patient has died at home — a patient that you may not even know (when covering for a colleague, for example). How could I possibly know what the cause of death is?

Turns out our best guesses have to suffice. I’d favor a system that produces more reliable data.

John Schumann is an internal medicine physician who blogs at GlassHospital.  

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  • Survivor DO

    Coudn’t agree more with the lack of training. I “learned” just as you described, by logging on to the online death certificated database and filling out my first death certificate after having to pronounce a patient dead. Worst of all, I was on call and barely even knew the patient. I hadn’t thought of the implications historically, perhaps I will be even more careful next time.

    Survivor DO

  • MarylandMD

    Back in medical school at the University of Maryland, the state medical examiners came in and gave us a class on how to fill out death certificates. They were very clear, and gave us handouts to use later on. Now, about 15 or so years later, I still remember the class, and I still have the handouts.

    It should be a standard part of the medical school curriculum. Too bad it wasn’t part of yours.

    In the end, we are often making an educated guess. Even when an autopsy is done, the cause isn’t always clear–so, while the medical examiners have more data available, even they are making an educated guess in a number of cases. We might have “more reliable data” if we did autopsies on everyone, but would it really be worth all the effort?

    No system is perfect. Do the best you can.

    For me the most important part of filling out a death certificate is making sure I call the family and pass along my sympathies and a few nice memories of my previous visits with the now deceased patient. No matter how hard it is for me to fill out the death certificate, they have it a lot worse.

    • glasshospital

      Hmmm. I went to a private school. Maybe there’s a lesson there. When content from 15 years ago sticks with you, you know it’s meaningful.

    • drg

      I went to U of Md. Med school about 25 years ago and never got that class! i think I would have remembered that one! Well it is good they have added that.

  • jeffj101604

    As an ME in a large city, we rely on clinicians to sign DCs for their patients or their group’s patients. More training is needed to understand the purpose of cause of death statements and what information is valuable to the public. We’ve worked with our county vital registration department to make references and training available. The CDC has a nice guide to signing DCs on their website. Briefly the purpose is to identify underlying diseases (and in industry also injuries) that start the physiologic path to death. You’re free to use terms like “probable.”

    Pneumonia and sepsis are red flags for MEs offices because they are too nonspecific to rule out trauma. Your vitals office may accept Something like Sepsis due to unspecified causes (non trauma related) with contributory diseases (like CAD or Alzheimer’s). Cardiac arrest (or brain dysfunction) are pathways common to all deaths and provide no valuable information (everyone who dies has these things).

    As far as evaluating your partner’s cases. Remember, your local ME has never seen your patient either. In natural deaths with history of potentially life threatening diseases, we’ll merely subpoena your records and issue a DC. You are in a better position to do this and, while we’d be happy to do this, there are not enough of us (~500 in the US, with need for 1000 to practice AS IS). Add another mandate and that needed number rises. We are publicly funded and recent politics doesn’t like publicly funding much of anything, so if you want additional help, lobby for your local ME.

    I can identify with your frustration about the modern lack of hospital autopsy data. JCAHO did a huge disservice to medicine and public health by eliminating rules requiring a certain percentage of in-house deaths be autopsied. Again, the most we can do is lobby your organization about the importance of this data in accurate conclusions about the death and accurate certification for vital stats.

    • glasshospital

      Thanks–this is a GREAT response. Much appreciated.

    • drg

      Wow! i though primary care was badly affeacted. But that is ridiculous 500 in the country and need double that now. I guess this is a morbid question but who pays for autopsies and how has the ME’s job changed in the last 25-30 years? Just like Primary care i am empathizing you have been hard hit by this and most are unaware.

  • TuckerBenson

    Cause of death is not the only thing that is frequently inaccurate on death certificates. Most death certificates ask for the full name and place of birth of the deceased person’s father and mother, including maiden name. You would be surprised how often a family member cannot supply this information.

    You might be the “informant” when the death certificate gets completed for your dad or mom. Do you know your GRANDmother’s maiden name, and where she was born?

  • ninguem

    Heh….try to get an autopsy.

    I had inherited a patient hospital admission, through the ER, with out-of-control blood pressure, heart failure, really multiorgan failure, with no doctor on the outside.

    Got various consultants involved, but really too late. Patient died. We had found a renal tumor, but died before we could further characterize it.

    So, I’m a total stranger to the family, just the doc standing around on duty when their loved one shows up dying. The family member that I have known for a couple days, dies under my care. Well, multiple people, but the family doc’s name is on top of the chart. I thought an autopsy would be a good idea. So did the family.

    I had to fight like hell for that autopsy. Our pathologist, a nice guy about the whole thing, part of a large metro area multisite pathology group, scratched his head, couldn’t remember the last time a patient at that hospital had had an autopsy.

    In the end, the deceased got an organ-specific autopsy limited to that diseased organ, nothing else.

    It was done by the pathology group’s PA.

    I didn’t even know pathologists employed physician’s assistants.

    “We don’t autopsy patients much anymore, a trend that concerns many in the industry but doesn’t seem likely to change.”

    So…..let me get this straight.

    YOU don’t do your effin’ job, and you bleat out concern that we don’t do it for you?

    I think I’d get censored if I told you what to do with your editorial.

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